Staff followed policy in calling 911 when the man collapsed on Monday, she said. "Our policy is under expedited review," Brown said.

That policy is a local one, she said.

The man's name hasn't been released.

News of the man's death spread Thursday at the Raymond G. Murphy VA Medical Center among veterans who were visiting for various medical reasons.

Lorenzo Calbert, 65, a U.S. Army veteran of the Vietnam War, said it was sad that a fellow veteran had to die so close to where he could have received help.

"There's no reason for it," he said. "They have so many workers. They could have put him on the gurney and run faster than that ambulance."

Paul Bronston, a California emergency-room physician and chair of Ethics and Professional Policy Committee of the American College of Medical Quality, said it may sound ridiculous that staff had to call 911 but that practice is the standard at hospitals. Typically, an ambulance would arrive faster, and other factors can stall workers trying to rush patients to the emergency room on foot, he said.

"The question I would have (is) ... was there an AED (automated external defibrillator) on site as required?" he said. Bronston said 90 percent of those who collapse are afflicted by heart problems and an AED could help them.

It was not known what caused the man to collapse or whether an AED was nearby.

The death comes as the Department of Veterans Affairs remains under scrutiny for widespread reports of long delays for treatment and medical appointments and of veterans dying while on waiting lists.

A review last week cited "significant and chronic system failures" in the nation's health system for veterans. The review also portrayed the struggling agency as one battling a corrosive culture of distrust, lacking in resources and ill-prepared to deal with an influx of new and older veterans with a range of medical and mental health care needs.

The scathing report by Deputy White House chief of staff Rob Nabors said the Veterans Health Administration, the VA sub agency that provides health care to about 8.8 million veterans a year, has systematically ignored warnings about its deficiencies and must be fundamentally restructured.

Marc Landy, a political science professor at Boston College, said the Department of Veterans Affairs is a large bureaucracy with various local policies like the one under review in Albuquerque.

Although the agency needs to undergo reform, Landy said it's unfair to attack the VA too harshly on the recent Albuquerque death because it appears to be so unusual.

"I think we have to be careful," he said. "Let's not beat up too much on the VA while they are already facing criticism."